Illustration of venoplasty procedure restoring blood flow in a blocked vein.

Venous Obstruction After Pacemaker or Defibrillator Implants: What Are Your Options?

Reese Marlowe in Health & Wellness December 2025 • 4 min read.

"A comprehensive guide to venoplasty and stenting techniques for managing venous obstruction in patients with cardiac implants, offering solutions to improve outcomes."

As cardiac resynchronization therapy (CRT) expands and cardiovascular disease survival rates increase, the need for lead revision and new lead placement grows. A significant hurdle is venous access when partial or complete vessel occlusion occurs, potentially complicating procedures. Subclavian venoplasty offers a less invasive solution, yet electrophysiologists rarely perform it due to a lack of formal training.

While primary venous obstruction during initial device implantation is uncommon, partial or complete obstruction from existing leads or previous instrumentation is fairly prevalent. Approximately 25% of patients with cardiac implantable electronic devices (CIEDs) experience some degree of venous obstruction, with severe or complete obstruction occurring in about 10% of these cases.

Given the frequency of venous obstruction, consider a pre-procedure peripheral venogram or non-invasive ultrasound for all patients undergoing a system upgrade or lead revision. Local venography can reveal a patent tract not apparent on peripheral venography, aiding guidewire manipulation across the occlusion.

Navigating Venous Obstruction: A Range of Solutions

Illustration of venoplasty procedure restoring blood flow in a blocked vein.

Historically, surgeons managed cardiac device implantation and, consequently, venous obstruction. Surgical techniques, such as tunneling or epicardial lead placement, were the norm. As interventional cardiology and electrophysiology evolved, so did management options for venous obstruction.

Several options exist when encountering venous obstruction. One of the least desirable is abandoning a functioning system and implanting a new one on the opposite side, which introduces redundant leads and the risk of future bilateral venous obstruction. Tunneling a new CIED lead across the sternum is another possibility, although it might compromise future venous access.

Abandoning access: Implanting a new system on the contralateral side.
Tunneling: Placing a new lead (e.g., left ventricular lead) across the sternum.
Epicardial placement: Surgical implantation of a lead.
Lead extraction: Mechanical or laser extraction of a redundant lead.
Subclavian venoplasty: A minimally invasive approach to open the blocked vein.

The decision between lead extraction with retained access and subclavian venoplasty often hinges on operator expertise and familiarity with the procedure. Venoplasty avoids sacrificing a functioning lead in system upgrades. Mastering venoplasty requires interventional knowledge and technical skills, which are not always part of standard cardiac electrophysiology training. In such cases, involving a physician with interventional cardiology or radiology training is advisable.

Key Takeaways for Managing Venous Obstruction

Venous obstruction during lead revision or device upgrades requires careful consideration. The goal is to select the least invasive and most effective strategy to ensure successful lead placement and optimal patient outcomes.

Subclavian venoplasty is a valuable technique that preserves functioning hardware and can be safely performed by implanting physicians with the right training and understanding of the necessary tools and techniques.

By carefully assessing each patient's specific needs and available resources, clinicians can navigate venous obstruction effectively and improve the long-term outcomes of cardiac device therapy.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.ccep.2018.07.005, Alternate LINK

Title: Venoplasty And Stenting

Subject: Physiology (medical)

Journal: Cardiac Electrophysiology Clinics

Publisher: Elsevier BV

Authors: Kevin P. Jackson

Published: 2018-12-01

Everything You Need To Know

What options are available to manage venous obstruction following a pacemaker or defibrillator implant?

Venous obstruction after cardiac device implantation can be addressed through various methods. These include abandoning access by implanting a new system on the opposite side, tunneling a new lead across the sternum, epicardial placement which involves surgical implantation, lead extraction to remove redundant leads, and subclavian venoplasty, a minimally invasive approach to open blocked veins. The selection depends on factors like operator skill and the specifics of the obstruction.

What is subclavian venoplasty, and when is it the preferred approach for venous obstruction?

Subclavian venoplasty is a minimally invasive procedure used to open blocked veins in patients with cardiac implants. It's particularly useful during lead revision or device upgrades, offering a way to restore venous access without sacrificing functioning leads. However, mastering subclavian venoplasty requires specialized interventional skills, which are not always part of standard cardiac electrophysiology training. When electrophysiologists lack this expertise, collaboration with interventional cardiology or radiology specialists is recommended.

How common is venous obstruction in patients with cardiac implantable electronic devices (CIEDs)?

Approximately 25% of patients with cardiac implantable electronic devices (CIEDs) experience some degree of venous obstruction. Severe or complete obstruction occurs in about 10% of these cases. Given this frequency, performing a pre-procedure peripheral venogram or non-invasive ultrasound is advisable for patients undergoing system upgrades or lead revisions to identify and plan for any obstructions.

Why might an electrophysiologist consult with an interventional cardiologist or radiologist when dealing with venous obstruction?

Electrophysiologists, while skilled in device implantation, may lack formal training in subclavian venoplasty. This expertise gap can make managing venous obstruction challenging. When encountering venous obstruction, electrophysiologists should consider collaborating with interventional cardiologists or radiologists who possess the necessary skills to perform venoplasty effectively. This collaboration ensures patients receive the most appropriate and effective treatment for venous obstruction, optimizing outcomes during lead revision or device upgrades.

When dealing with venous obstruction, what considerations guide the choice between lead extraction and subclavian venoplasty?

Faced with venous obstruction, choosing between lead extraction and subclavian venoplasty depends on operator expertise and the specifics of the case. Venoplasty offers the advantage of preserving a functioning lead, which is crucial during system upgrades. However, if the operator lacks venoplasty skills, lead extraction might seem simpler, though it sacrifices a working lead. The ideal approach aims for the least invasive and most effective solution to ensure successful lead placement and positive patient outcomes.